TEASDALE FOODS, INC. has sponsored the creation of one or more 401k plans.
Additional information about TEASDALE FOODS, INC.
Submission information for form 5500 for 401k plan TEASDALE FOODS, INC.
401k plan membership statisitcs for TEASDALE FOODS, INC.
| Measure | Date | Value |
|---|
| 2022: TEASDALE FOODS, INC. 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 814 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 896 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 897 |
| 2021: TEASDALE FOODS, INC. 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 879 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 836 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 844 |
| 2020: TEASDALE FOODS, INC. 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 873 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 1,000 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 1,006 |
| 2019: TEASDALE FOODS, INC. 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 1,347 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 1,158 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 1,159 |
| 2018: TEASDALE FOODS, INC. 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 475 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 783 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 783 |
| 2017: TEASDALE FOODS, INC. 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 409 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 475 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 475 |
| 2016: TEASDALE FOODS, INC. 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 409 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 409 |
| 2015: TEASDALE FOODS, INC. 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 144 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 144 |
| 2014: TEASDALE FOODS, INC. 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 283 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 301 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 301 |
| 2013: TEASDALE FOODS, INC. 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 109 |
| Total of all active and inactive participants | 2013-01-01 | 109 |
| 2012: TEASDALE FOODS, INC. 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 109 |
| Total of all active and inactive participants | 2012-01-01 | 109 |
| 2011: TEASDALE FOODS, INC. 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-09-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 109 |
| Total of all active and inactive participants | 2011-09-01 | 109 |
| 2022: TEASDALE FOODS, INC. 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: TEASDALE FOODS, INC. 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: TEASDALE FOODS, INC. 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: TEASDALE FOODS, INC. 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: TEASDALE FOODS, INC. 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: TEASDALE FOODS, INC. 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: TEASDALE FOODS, INC. 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | Yes |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: TEASDALE FOODS, INC. 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: TEASDALE FOODS, INC. 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: TEASDALE FOODS, INC. 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: TEASDALE FOODS, INC. 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: TEASDALE FOODS, INC. 2011 form 5500 responses |
|---|
| 2011-09-01 | Type of plan entity | Single employer plan |
| 2011-09-01 | First time form 5500 has been submitted | Yes |
| 2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-09-01 | Plan funding arrangement – Insurance | Yes |
| 2011-09-01 | Plan benefit arrangement – Insurance | Yes |
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 71958-7 |
| Policy instance | 4 |
| Insurance contract or identification number | 71958-7 | | Number of Individuals Covered | 1085 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,299 | | Total amount of fees paid to insurance company | USD $5,491 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $274,562 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5491 | | Additional information about fees paid to insurance broker | MARKETING FEE | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $4,299 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 304050 |
| Policy instance | 3 |
| Insurance contract or identification number | 304050 | | Number of Individuals Covered | 888 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $14,758 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,879,715 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 14758 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12206119 |
| Policy instance | 2 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 466 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 1 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 114 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $787,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282306 |
| Policy instance | 1 |
| Insurance contract or identification number | 282306 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $262,780 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 2 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 114 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $722,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 3 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 471 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 304050 |
| Policy instance | 4 |
| Insurance contract or identification number | 304050 | | Number of Individuals Covered | 980 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,644,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 71958-7 |
| Policy instance | 5 |
| Insurance contract or identification number | 71958-7 | | Number of Individuals Covered | 1051 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $16,992 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $254,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,992 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282306 |
| Policy instance | 1 |
| Insurance contract or identification number | 282306 | | Number of Individuals Covered | 621 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,808,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CHC5238 |
| Policy instance | 2 |
| Insurance contract or identification number | CHC5238 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $96,686 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00546000 |
| Policy instance | 3 |
| Insurance contract or identification number | 00546000 | | Number of Individuals Covered | 535 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $462 | | Total amount of fees paid to insurance company | USD $3,469 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $416,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3469 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $462 |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 4 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 136 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $905,753 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 5 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 736 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $390,146 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 6 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 515 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282306 |
| Policy instance | 1 |
| Insurance contract or identification number | 282306 | | Number of Individuals Covered | 594 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $13,812 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,692,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 13812 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CHC5238 |
| Policy instance | 2 |
| Insurance contract or identification number | CHC5238 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $165,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00546000 |
| Policy instance | 3 |
| Insurance contract or identification number | 00546000 | | Number of Individuals Covered | 567 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $462,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 4 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 169 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $953,797 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 5 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 808 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $405,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 6 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 556 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0063645 |
| Policy instance | 6 |
| Insurance contract or identification number | W0063645 | | Number of Individuals Covered | 872 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,286 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0063645 |
| Policy instance | 5 |
| Insurance contract or identification number | W0063645 | | Number of Individuals Covered | 475 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $58 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,281,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 58 | | Additional information about fees paid to insurance broker | MISC. GIFTS, MEALS & ENTERTAINMENT ALLOCATION: | | Insurance broker organization code? | 3 | | Insurance broker name | CRYSTAL IBC LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 4 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1059089 |
| Policy instance | 3 |
| Insurance contract or identification number | 1059089 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $104,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 332371 |
| Policy instance | 2 |
| Insurance contract or identification number | 332371 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,261 | | Total amount of fees paid to insurance company | USD $922 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $52,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,261 | | Amount paid for insurance broker fees | 922 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | CRYSTAL IBC LLC |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 10699 |
| Policy instance | 1 |
| Insurance contract or identification number | 10699 | | Number of Individuals Covered | 433 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $246,940 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10106717 |
| Policy instance | 2 |
| Insurance contract or identification number | 10106717 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $29,131 | | Total amount of fees paid to insurance company | USD $2,769 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $108,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,180 | | Amount paid for insurance broker fees | 2769 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | EMPLOYER PLAN SERVICES, INC. |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1059089 |
| Policy instance | 3 |
| Insurance contract or identification number | 1059089 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 869514 |
| Policy instance | 4 |
| Insurance contract or identification number | 869514 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $49,246 | | Total amount of fees paid to insurance company | USD $253 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,855,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,868 | | Amount paid for insurance broker fees | 253 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CRYSTAL AND COMPANY |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 5 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $287 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $287 | | Insurance broker organization code? | 3 | | Insurance broker name | CRYSTAL AND COMPANY |
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| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 10699 |
| Policy instance | 1 |
| Insurance contract or identification number | 10699 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,376 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $179,200 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,599 | | Insurance broker organization code? | 3 | | Insurance broker name | CRYSTAL AND COMPANY |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 10699 |
| Policy instance | 3 |
| Insurance contract or identification number | 10699 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,682 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $156,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,682 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 901661 |
| Policy instance | 2 |
| Insurance contract or identification number | 901661 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $69,636 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,906,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,636 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 1 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,248 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,001 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,248 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 ) |
| Policy contract number | 303874 |
| Policy instance | 4 |
| Insurance contract or identification number | 303874 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,840 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00332371 |
| Policy instance | 5 |
| Insurance contract or identification number | 00332371 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $11,431 | | Total amount of fees paid to insurance company | USD $3,003 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,453 | | Amount paid for insurance broker fees | 3003 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WOODY FINANCIAL GROUP, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 1 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $982 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $982 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | C20664 |
| Policy instance | 2 |
| Insurance contract or identification number | C20664 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,888 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C20664 |
| Policy instance | 3 |
| Insurance contract or identification number | C20664 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $74,670 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,856,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,670 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 10699 |
| Policy instance | 4 |
| Insurance contract or identification number | 10699 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,135 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $137,826 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,135 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 10699 |
| Policy instance | 4 |
| Insurance contract or identification number | 10699 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $4,005 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $133,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,005 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C20664 |
| Policy instance | 3 |
| Insurance contract or identification number | C20664 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $75,527 | | Total amount of fees paid to insurance company | USD $132 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,442,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 132 | | Additional information about fees paid to insurance broker | BONUS/OVERRIDE/NON-MONETARY | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $75,527 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 1 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $961 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $961 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | C20664 |
| Policy instance | 2 |
| Insurance contract or identification number | C20664 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 10699 |
| Policy instance | 4 |
| Insurance contract or identification number | 10699 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,316 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,858 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C20664 |
| Policy instance | 3 |
| Insurance contract or identification number | C20664 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $28,295 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $559,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | C20664 |
| Policy instance | 2 |
| Insurance contract or identification number | C20664 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2011-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12206119 |
| Policy instance | 1 |
| Insurance contract or identification number | 12206119 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $266 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,704 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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